MEDICAL STUDENT EDUCATIONAL OBJECTIVES

for

THE DEPARTMENT OF OBSTETRICS AND GYNECOLOGY

at the

Texas Tech University Health Sciences Center

Lubbock Campus

Approach to the Patient

HISTORY

Rationale: A gynecological evaluation is an important part of primary health care and preventive medicine for women. A gynecological assessment should be a part of every womans' general medical history and physical examination. Certain questions must be asked of every woman, whereas other questions are specific to particular problems. To accomplish these objectives, optimal communication must be achieved between patient and physician.

The student will demonstrate the ability to: A. Perform a thorough obstetric-gynecologic history as a portion of a general medical history, including the following: 1. Chief complaint 2. Present illness 3. Menstrual history 4. Obstetric history 5. Gynecologic history 6. Contraceptive history 7. Sexual history 8. Family history 9. Social history B. Interact with the patient to gain her confidence and to develop an appreciation of the effect of her age, racial and cultural background, and economic status on her health C. Communicate the results of the obstetric-gynecologic and general medical history by well-organized written and oral reports.

EXAMINATION

Rationale: An accurate examination complements the history, provides additional information and helps determine diagnosis and guide management. It also provides an opportunity to educate and reassure the patient.

The student will demonstrate the ability to: A. Interact with the patient to gain her confidence and cooperation, and assure her comfort and modesty B. Perform a painless obstetric-gynecologic examination as part of a woman’s general medical examination, including: 1. Breast examination 2. Abdominal examination 3. Complete 4. Recto-vaginal examination C. Communicate the relevant results of the examination in well-organized written and oral reports. D. Share results E. Educate the patient regarding breast self examination

PAP SMEAR AND CULTURES

Rationale: The Pap smear is one of many screening methods used in medicine. Proper technique in performing the Pap smear and obtaining specimens for microbiologic culture will improve accuracy.

The student will demonstrate the ability to: A. perform an adequate Pap smear B. Obtain specimens to detect sexually transmitted diseases C. Handle specimens properly to improve diagnostic accuracy D. Provide an explanation to the patient regarding the purpose of these test

DIAGNOSIS AND MANAGEMENT PLAN

Rationale: Accurately identifying problems and selecting the most likely diagnosis leads to effective management plans.

After completing the history and physical examination, the student will demonstrate the ability to: A. Generate a problem list B. Form a diagnostic impression including differential diagnosis C. Consider economic and psychosocial issues D. Develop a management plan that includes: 1. Laboratory and diagnostic studies 2. Treatment 3. Patient education 4. Continuing care plans

PERSONAL INTERACTION AND COMMUNICATION SKILLS

Rationale: The ability to interact cooperatively with a patient and all members of a health care team is a hallmark of professionalism.

The student will demonstrate the ability to: A. Establish rapport with patients B. Work cooperatively with patients, their social supports, and other members of the health care team C. Assess his/her own strengths and weaknesses with regard to personal interactions

LEGAL ISSUES IN OBSTETRICS AND GYNECOLOGY

Rationale: Legal obligations to protect patient's interests are effective only if understood and applied.

The student will be able to explain the following: A. Informed consent 1. Right to refuse care 2. Outcomes 3. Options/alternatives 4. Capacity to choose 5. Surrogate decision makers B. Advance directives for health care C. Confidentiality D. Abandonment E. Contractual nature of medical benefits F. Fraud G. Risk management H. Local laws requiring the reporting of suspected child abuse and domestic violence

ETHICS IN OBSTETRICS AND GYNECOLOGY

Rationale: Recognizing and understanding the bases of ethical conflicts in obstetrics and gynecology will allow better patient care and prevent critical errors in treatment planning.

The student will be able to: A. Apply a systematic approach to ethical problems B. Explain issues of justice relating to access to obstetric-gynecologic care C. Explain the basis of ethical conflict in maternal-fetal medicine D. Discuss ethical issues raised by induced abortion and contraception E. Discuss ethical issues raised by reproductive technology

PREVENTIVE CARE AND HEALTH CARE MAINTENANCE

Rationale: The student will recognize the value of routine health surveillance as a part of health promotion and disease prevention. The student will be able to list the following: A. Age appropriate screening procedures and recommended time intervals for: 1. Blood pressure monitoring 2. Immunizations 3. Mammogram 4. Pap smear 5. Blood lipid profiles B. The student will be able to counsel the patient regarding: 1. Contraception 2. Prevention of sexually transmitted disease 3. Diet 4. Exercise 5. Stress management 6. Smoking cessation 7. Substance abuse 8. Seat belt use 9. Sun exposure 10. Local specific risks 11. Depression C. The student will be able to evaluate the cost and benefits of routine health surveillance D. The student will be able to explain prevention guidelines for the following: 1. Breast 2. 3. Colon 4. Cardiovascular 5. Skin 6. Bones 7. Eyes 8. Immunizations

General Gynecology

CONTRACEPTION

Rationale: An understanding of the medical and personal issues involved in decisions regarding contraceptive methods is necessary to adequately advise patients requesting contraception.

The student will be able to explain: A. Physiologic or pharmacologic basis of action B. Effectiveness C. Benefits and risks D. Financial considerations of the various methods of contraception

STERILIZATION

Rationale: In the process of deciding whether to have a sterilization procedure, men and women often seek the advice of their physicians. Providing accurate information will allow patients to make an informed decision regarding this elective surgery.

The student will be able to list: A. Methods of male and female surgical sterilization B. Risks and benefits of procedures C. Factors needed to help the patient make informed decisions, including: 1. Potential surgical complications 2. Failure rates 3. Reversibility D. Financial considerations

ABORTION

Rationale: Induced abortion is a reproductive option considered by some patients. Regardless of one’s personal views, the practitioner should be aware of the techniques, management, and complications of induced abortions.

The student will be able to list: A. Surgical and non-surgical pregnancy termination methods B. Potential complications of abortion, such as 1. Hemorrhage 2. Infection C. Psychosocial considerations of abortion VULVAR AND VAGINAL DISEASE

Rationale: Vaginal and vulvar symptoms are frequent patient concerns. In order to provide appropriate care, the physician must understand the common etiologies of these problems as well as appropriate diagnostic and management options.

The student will be able to describe: A. Normal vaginal appearance and secretions B. Evaluation and management of common vulvar and vaginal problems including: 1. due to bacteria, fungi, trichomonads, viruses, foreign bodies, and atrophy 2. Dermatologic conditions of the 3. Bartholin’s gland disease 4. 5. Trauma

SEXUALLY TRANSMITTED INFECTIONS

Rationale: To prevent sexually transmitted infections and minimize their impact on health, the physician should understand their basic epidemiology, diagnosis, and management.

The student will be able to list: A. Organisms and methods of transmission, symptoms, physical findings and evaluation and management of each of the following: 1. 2. 3. virus 4. 5. Human papillomavirus infection 6. Human immunodeficiency virus (HIV) infection 7. Hepatitis B virus infection B. Public health concerns, including: 1. Screening programs 2. Costs 3. Prevention and immunizations 4. Partner evaluation and treatment

SALPINGITIS

Rationale: The potential impact of acute or chronic is significant. Early recognition and optimal management may help prevent the long-term sequelae of tubal disease.

The student will be able to describe: A. Pathogenesis B. Common organisms C. Signs and symptoms D. Methods of diagnosis E. Treatment F. Sequelae, including: 1. Tuboovarian abscess 2. Chronic salpingitis 3. 4.

PELVIC RELAXATION AND URINARY INCONTINENCE

Rationale: Patients with conditions of pelvic relaxation and urinary incontinence present in a variety of ways. The physician should be familiar with the types of pelvic relaxation and incontinence and the approach to management of these patients.

The student will demonstrate knowledge of the following: A. Predisposing risk factors for and incontinence B. Anatomic changes, fascial defects and neuromuscular pathophysiology C. Signs and symptoms of pelvic organ prolapse D. Physical exam 1. 2. 3. 4. Vaginal vault or E. Methods of diagnosis: 1. Urine culture 2. Post-void residual 3. Cystoscopy 4. Urodynamic testing F. Nonsurgical and surgical treatments including: 1. Pessary 2. Medications 3. Reconstructive surgery

ENDOMETRIOSIS

Rationale: is a common problem of women of reproductive age, which may result in , infertility, and menstrual dysfunction.

The student will be able to describe: A. Theories of pathogenesis B. Symptoms and physical findings C. Common sites of implants D. Methods of diagnosis E. Non-surgical and surgical management

CHRONIC PELVIC PAIN

Rationale: Every physician should understand the chronic pelvic pain might be the manifestation of a variety of problems.

The student will be able to: A. Define chronic pelvic pain B. Cite the incidence and etiologies C. Cite clinical manifestations D. Cite diagnostic procedures E. List management options

DISORDERS OF THE BREAST

Rationale: Every physician should understand the basic approach to evaluating the common symptoms associated with the breast.

The student will be able to: A. Describe: 1. Standards of surveillance of an adult woman, including breast self- examination, physical examination, and mammography 2. Diagnostic approach to a woman with the chief complaint of breast mass, nipple discharge, or breast pain 3. History and physical findings that might suggest the following abnormalities: a. Intraductal papilloma b. Fibrocystic changes c. Fibroadenoma d. Carcinoma e. Mastitis B. Teach a woman how to perform breast self-examination GYNECOLOGIC PROCEDURES

Rationale: Evaluation and management of gynecologic problems frequently requires performing diagnostic and therapeutic surgical procedures. Understanding the risks and benefits of such procedures is important in counseling patients about their options for treatment and reasons for having the procedures performed.

The student will be able to counsel a patient regarding the risks, benefits, and financial considerations of the following procedures: A. and cervical biopsy B. Cone biopsy C. Cryotherapy D. Culdocentesis E. F. Electrosurgical excision of cervix G. H. I. J. K. Laparoscopy L. Laser vaporization M. Mammography N. Needle aspiration of breast mass O. Pelvic ultrasonography P. Pregnancy termination Q. Vulvar biopsy

General Obstetrics

PHYSIOLOGIC CHANGES IN PREGNANCY

Terminal objective Given a patient with an early intrauterine pregnancy, the student should be able to provide comprehensive prenatal care based on knowledge of maternal and fetal physiology as demonstrated through the contents of patients’ records, history, and physical examination.

Enabling objectives

1. List the major changes in the maternal reproductive tract during pregnancy and the c common clinical problems associated with them, including: a. Gross and microscopic structure b. Uteroplacental blood flow c. Myometrial biochemistry and biophysics 2. List the changes in the breasts during pregnancy and their clinical signifance in terms of: a. Gross and microscopic structure b. Endocrine preparation for lactation c. Secretion and ejection of milk d. Physical examination 3. List the major changes in the maternal cardiovascular system, and relate these changes to expected symptomatology and developing clinical signs, including: a. Cardiac output and blood volume b. Regional blood flow in uteroplacental, renal, cerebral, mesenteric, hepatic; and cutaneous vascular beds c. Effects of body position, including consideration of cardiac output distribution and venous pressure d. Hematopoietic and coagulation mechanisms 4. List the major anatomic and functional changes in the maternal urinary tract and in the dynamics of fluid and electrolytes, and relate these changes to expected symptomatology during pregnancy, including: a. Glomerular filtration rate, renal plasma flow, and tubular function b. The renal collecting system c. Body fluid regulation, including sodium and water balance d. Postural effects on nephron function e. Renin-angiotensin-aldosterone system changes 5. List the major changes in the maternal respiratory tract, and relate these changes to expected symptomatology, including: a. Ventilatory mechanics b. Chemical respiratory factors c. Measurement of respiratory volumes and function 6. List the major changes in the maternal gastro-intestinal tract, and relate these changes to expected symptomatology during pregnancy, including: a. Gastric motility and secretions b. Gastroesophageal reflux and hiatus hernia c. Colonic function d. Gallbladder function 7. List the major skin changes in pregnancy 8. Discuss the effects of pregnancy in producing musculoskeletal symptoms 9. List the common psychologic changes in each trimester of pregnancy, and relate these changes to physiologic changes. 10. Discuss the special needs of working women 11. Discuss the special needs of adolescent/single women.

ANTEPARTUM CARE

Terminal objective Given a patient contemplating pregnancy, the student should be able to counsel the patient regarding the advisability of pregnancy.

Enabling objectives

1. Employ history to predict the risk of fetal anomaly and complications of pregnancy 2. Discuss the risk of pregnancy in comparison with the risk of contraception, pregnancy termination, and sterilization. 3. Evaluate the impact of pregnancy on the patient’s interpersonal relationships 4. Help the patient evaluate her ability to provide the necessary social and economic support for the child 5. Support the patient’s decision regarding pregnancy after providing an adequate explanation of risks and rewards 6. Institute preventive care for the patient who wishes to become pregnant in order to optimize conditions for pregnancy and to provide necessary education on nutrition, drug ingestion, and immunization.

Terminal objective Given a patient in the first trimester of pregnancy, the student should be able to obtain an appropriate history; perform a complete physical examination, including pelvic measurements; obtain appropriate laboratory data; assess the current status of the patient; anticipate potential problems; counsel the patient concerning nutrition, hygiene, danger signs in pregnancy, the current status, and potential problems, and administer continuing comprehensive antepartum care.

Enabling objectives

1. State the elements of history useful in assessing the current pregnancy 2. Recognize the significant deviations from normal in the physical examination 3. List the important laboratory tests. 4. Discuss the interpretation of rubella antibody. 5. List the factors that place a gravida in the high-risk category. 6. State the important factors to be assessed at each prenatal visit.

LABOR AND DELIVERY

Terminal objective Given a patient near term with regular uterine contractions, the student should be able to manage labor and delivery successfully

Enabling objectives

1. List techniques for assessing fetal well being during labor, and apply fetal monitoring techniques, identifying the relationship of fetal heart rate changes to uterine contraction patterns and progress in labor. 2. Discuss obstetric mechanisms (e.g. breech, occiput posterior, face presentations) and the stress of the delivery process on maternal tissues (e.g. levator ani, urogenital diaphragm, endopelvic fascia) 3. Identify criteria to assess the clinical condition of the newborn by Apgar score, as well as cardiorespiratory and CNS phenomena, and list criteria for immediate pediatric consultation or special newborn care.

PUERPERIUM

Terminal objective Given a patient who has recently delivered vaginally at term, the student should demonstrate skill in monitoring the normal recovery process, including recognition, evaluation, and management of problems of the puerperium.

Enabling objectives

1. Describe the recovery from the physiologic changes of pregnancy and delivery and the restoration of the normal nonpregnant state in the reproductive tract, the urinary tract, skin, metabolic system, and endocrine system. 2. Define bonding; discuss the process in the human and its implications for mother and baby 3. Manage the emotional, social, and sexual problems of the puerperal patient and her family. 4. Counsel the puerperal patient regarding physical activities, sexual activity, and contraception. 5. Discuss the role and advantages of rooming-in.

FETAL HEART RATE MONITORING

Terminal objective List the causes of abnormal heart rate patterns, outline a plan of management for each cause, and demonstrate ability to use external and internal fetal monitoring techniques. Describe the conditions that alter the fetal heart rate and the pathophysiologic mechanisms by which the changes occur.

High Risk Obstetrics

POSTPARTUM HEMORRHAGE AND OBSTETRIC SHOCK

Enabling objectives

1. Define postpartum hemorrhage 2. List in order of probability the causes of excessive bleeding and shock in the postpartum patient. 3. Outline a step-by-step approach to determine the cause of postpartum hemorrhage 4. Describe the management of each cause of postpartum hemorrhage 5. List the possible immediate and remote complications, and describe the management of each. 6. Outline methods for prevention of each cause of postpartum hemorrhage 7. Outline the management of the patient in shock as a result of postpartum hemorrhage

PRETERM LABOR

Enabling objectives

1. Define preterm labor 2. List and describe the diagnostic procedures that provide the information necessary to decide whether to inhibit uterine contractions. 3. List the available tocolytic agents, discuss the mechanisms of action of each agent, describe their beneficial and adverse pharmacologic actions, and integrate them into a treatment plan, if appropriate.

HYPERTENSION IN PREGNANCY

Enabling objectives

1. List the types of hypertensive diseases that complicate pregnancy, and state the diagnostic criteria for each: a. Acute preeclampsia-eclampsia b. Chronic hypertension c. Preeclampsia superimposed on chronic hypertensive renal disease d. Transient hypertension.

PREMATURE RUPTURE OF THE MEMBRANES

Terminal objective Given a pregnant patient with vaginal fluid leakage, the student should be able to perform the procedures necessary to make a diagnosis, describe the potential complications for mother and fetus, and develop and conduct a management plan based on existing conditions and anticipated complications.

Enabling objectives

1. List common obstetric complications that occur with premature rupture of the membranes. 2. Discuss the theoretical basis for the use of antepartum glucocorticoid therapy, indications, contraindications, and hazards.

Gynecologic Oncology (Neoplasia)

GESTATIONAL TROPHOBLASTIC NEOPLASIA

Rationale: Gestational trophoblastic neoplasia is important because its malignant potential and the associated risks of morbidity and mortality.

The student will be able to describe: A. Symptoms and physical findings B. Diagnostic methods C. Management and follow-up

VUVLAR NEOPLASMS

Rationale: Proper evaluation of vulvar symptoms allows for early recognition and diagnosis of neoplasia which can improve outcome and may avoid the need for extensive surgery.

The student will be able to describe: A. Risk factors of vulvar neoplasms B. Methods of diagnosis C. Diagnosis and management

CERVICAL DISEASE AND NEOPLASIA

Rationale: Detection and treatment of preinvasive lesion reduces the medical and social costs of, as well as the mortality associated with, carcinoma of the cervix.

The student will be able to describe: A. Risk factors of cervical disease and neoplasia B. Indications for screening C. Symptoms and physical findings of and neoplasia D. Evaluation and management of the patient with an abnormal pap smear E. Impact of staging on management and prognosis

UTERINE LEIOMYOMAS

Rationale: Uterine leiomyomas represent the most common gynecologic neoplasm and are often asymptomatic.

The student will be able to describe the following: A. Prevalence of uterine leiomyomas B. Symptoms and physical findings C. Methods to confirm the diagnosis D. Indications for medical and surgical treatment

ENDOMETRIAL CARCINOMA

Rationale: Endometrial carcinoma is the most common gynecologic malignancy.

The student will be able to describe: A. Risk factors for endometrial carcinoma B. Symptoms and physical findings C. Management of the patient with postmenopausal bleeding D. Methods to diagnose endometrial carcinoma E. Impact of staging on management and prognosis F. Management of the patient with endometrial cancer

OVARIAN NEOPLASMS

Rationale: Adnexal masses are a common finding in both symptomatic and asymptomatic patients. Management is base on determining the origin and character of these masses.

The student will be able to describe: A. Evaluation of the patient with an B. Characteristics of: 1. Functional cysts 2. Benign neoplasms 3. Carcinomas C. Evaluation and management of carcinomas of the 1. Symptoms and physical findings 2. Risk factors 3. Histologic classification D. Impact of staging on management and prognosis

Reproductive Endocrinology and Infertility

PUBERTY

Rationale: The maturation of the reproductive system at the time of puberty is accompanied by physical and emotional changes that are part of this normal transition. In order to provide appropriate care and counseling, the physician must have an understanding of the normal sequence of puberty and recognize deviation from the norm.

The student will be able to describe: A. Normal puberty, including: 1. Physiological events that take place in the hypothalamic-pituitary- ovarian axis and their target organs. 2. Sequence of, and expected ages at which these changes occur 3. Psychological aspects B. Abnormal puberty, including: 1. Characteristics, causes, and diagnostic approach to early or delayed puberty onset.

AMENORRHEA

Rationale: The absence of normal menstrual bleeding may represent an anatomic or endocrine problem. A systematic approach to the evaluation of will aid in the diagnosis and treatment of its causes.

The student will be able to list: A. Definitions of primary amenorrhea, secondary amenorrhea, and B. Causes of amenorrhea C. Evaluation methods D. Treatment options

HIRSUTISM AND VIRILIZATION

Rationale: The signs and symptoms of androgen excess in a woman may cause anxiety and may represent serious underlying disease.

The student will be able to: A. Cite normal variations in secondary sex characteristics B. List definitions of hirsutism and virilization C. List causes including ovarian, adrenal, pituitary, and pharmacological D. Evaluate the patient with hirsutism or virilization

NORMAL AND ABNORMAL UTERINE BLEEDING

Rationale: The occurrence of bleeding at times other than expected menses a common event. Accurate diagnosis of abnormal uterine bleeding is necessary for appropriate management.

The student will be able to: A. Describe endocrinology and physiology of the normal menstrual cycle B. Distinguish abnormal uterine bleeding from dysfunctional uterine bleeding C. List causes of abnormal uterine bleeding D. Evaluate and diagnose abnormal uterine bleeding E. Describe therapeutic options

DYSMENORRHEA

Rationale: is often the impetus for women to seek health care. Accurate diagnosis guides effective treatment.

The student will be able to cite the following: A. Definitions of primary and secondary dysmenorrhea B. Causes of dysmenorrhea C. Management strategies

CLIMACTERIC

Rationale: Women spend as much as one-third of their lives in the postmenopausal years. Understanding the physical and emotional changes caused by estrogen depletion is important for all physicians who provide health care for women.

The student will be able to describe: A. Physiologic changes in the hypothalamic-pituitary-ovarian axis B. Symptoms and physical findings associated with hypoestrogenism C. Long-term changes associated with hypoestrogenism D. Management, including: 1. Hormone therapy 2. Nutrition and exercise 3. Non-hormonal therapeutic options E. Risks and benefits of hormone replacement therapy

INFERTILITY

Rationale: The evaluation and management of an infertile couple requires an understanding of the processes of conception and embryogenesis, as well as sensitivity to the emotional stress that can result from the inability to conceive.

The student will be able to cite: A. Definition of primary and secondary infertility B. Causes of male and C. Evaluation and management D. Psychosocial issues associated with infertility

PREMENSTRUAL SYNDROME (PREMENSTRUAL DYSPHORIA DISORDER)

Rationale: involves physical and emotional discomfort and may affect interpersonal relationships. Effective management of this condition requires an understanding of symptoms and diagnostic methods.

The student will be able to cite: A. Definition of premenstrual syndrome B. Theories of etiology C. Methods of diagnosis D. Management strategies

Human Sexuality

SEXUALITY

Rationale: All physicians should be able to provide a preliminary assessment of patients with sexual concerns and make referrals when appropriate.

The student will be able to describe: A. Physiology of male and female sexual response B. Physiologic, emotional, and societal influences on sexuality during the following life events: 1. Childhood 2. Adolescence 3. Reproductive years 4. Post-reproductive years C. Patterns of sexual function and dysfunction

MODES OF SEXUAL EXPRESSION

Rationale: Detection and management of a woman’s health care problems may be affected by her means of sexual expression.

The student will be able to contrast the sexual behavior patterns and social issues of people who are: A. Heterosexual B. Homosexual C. Bisexual D. Transgender

PHYSICIAN SEXUALITY

Rationale: A patient’s willingness to discuss her sexual concerns with her physician is often a function of the physician’s own comfort with these issues.

The student will consider that: A. The student's own sexuality may influence self-awareness of the perception and management of patients B. Behavior patterns of seductive patients C. Appropriate boundaries of physician behavior

Violence Against Women

SEXUAL ASSAULT

Rationale: Individuals who are the victims of sexual assault often have significant physical and emotional sequelae.

The student will be able to explain the medical, forensic, psychological evaluation and treatment, and follow-up of: A. Child sexual assault victim B. Adult sexual assault victim C. Acquaintance rape

DOMESTIC VIOLENCE

Rationale: Domestic violence affects a significant proportion of the US population in all economic classes and walks of life. All physicians should screen for the presence of domestic violence.

The student will be able to: A. Cite prevalence and incidence of violence against women, elder abuse, child abuse B. Assess the involvement of any patient in domestic violence situations C. Counsel patients for short term safety D. Counsel patients regarding local support agencies for long term management and resources E. Counsel patients requiring resources for batterers and perpetrators of domestic violence